Member Handbook (Evidence of Coverage) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Virginia Member Services: 1-855-817-5787 (TTY: 1-800-255-2880) Monday through Friday 8 a.m to 8 p.m. local time mss.anthem.com/ccc Y0071_14_19073_U CMS Accepted 02/10/2014
Y0071_14_19460_T CMS Approved 03/28/2014 Anthem HealthKeepers Medicare-Medicaid Plan (MMP) A Commonwealth Coordinated Care Plan Member Handbook April 1, 2014 December 31, 2014 Your Health and Drug Coverage under the Anthem HealthKeepers Medicare-Medicaid Plan (MMP) This handbook tells you about your coverage under Anthem HealthKeepers MMP, a Commonwealth Coordinated Care plan, through December 31, 2014. It explains health care services, behavioral health coverage, prescription drug coverage, and long-term services and supports. Long-term services and supports help you stay at home instead of going to a nursing facility or hospital. This is an important legal document. Please keep it in a safe place. This Anthem HealthKeepers Medicare-Medicaid Plan is offered by HealthKeepers, Inc. When this Member Handbook says we, us, or our, it means HealthKeepers, Inc. When it says the plan or our plan, it means Anthem HealthKeepers MMP. You can get this handbook for free in other languages. Call 1-855-817-5787 (TTY: 1-800- 855-2880) Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free. Usted puede obtener este manual gratuitamente en otros idiomas. Llame al 1-855-817-5787 (TTY: 1-800-855-2884)] de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. You can ask for this handbook in other formats, such as Braille or large print. Call 1-855-817-5787 (TTY: 1-800-855-2880) Monday through Friday from 8 a.m. to 8 p.m. local time. Usted puede pedir este manual en otros formatos, tales como Braille o letras grandes. Llame al 1-855-817-5787 (TTY: 1-800-855-2884)] de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. Disclaimers HealthKeepers, Inc. is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services (Medicaid) to provide benefits of both programs to enrollees. Y0071_14_19460_T CMS Approved 03/28/2014 1
Chapter 1: Getting started as a member Limitations, copays and restrictions may apply. For more information, call Anthem HealthKeepers MMP Member Services or read the Anthem HealthKeepers MMP Member Handbook. This means that you may have to pay for some services and that you need to follow certain rules to have HealthKeepers, Inc. pay for your services. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Y0071_14_19460_T CMS Approved 03/28/2014 2
Chapter 1: Getting started as a member Chapter 1: Getting started as a member Table of Contents A. Welcome to Anthem HealthKeepers MMP... 4 B. What are Medicare and Medicaid... 4 Medicare... 4 Medicaid... 4 C. What are the advantages of this plan... 5 D. What is Anthem HealthKeepers MMP s service area... 5 E. What makes you eligible to be a plan member... 6 F. What to expect when you first join a health plan... 6 G. What is a care plan... 7 H. Does Anthem HealthKeepers MMP have a monthly plan premium... 7 I. About the Member Handbook... 7 J. What other information will you get from us... 7 Your Anthem HealthKeepers MMP member ID card... 8 Provider and Pharmacy Directory... 8 List of Covered Drugs... 9 The Explanation of Benefits... 10 K. How can you keep your membership record up to date... 10 Do we keep your personal health information private... 11 Y0071_14_19460_T CMS Approved 03/28/2014 3
Chapter 1: Getting started as a member Welcome to Anthem HealthKeepers MMP Anthem HealthKeepers MMP is a Medicare-Medicaid Plan in the Commonwealth Coordinated Care (CCC) Program. A Medicare-Medicaid plan is an organization made up of doctors, hospitals, pharmacies, providers of long-term services and supports, and other providers. It also has care managers and care teams to help you manage all your providers and services. They all work together to provide the care you need. Anthem HealthKeepers MMP was approved by the State and the Centers for Medicare & Medicaid Services (CMS) to provide you services as part of the CCC Program. The CCC Program is a demonstration program jointly run by the Commonwealth of Virginia and the federal government to provide better health care for people who have both Medicare and Medicaid. Under this demonstration, the state and federal government want to test new ways to improve how you receive your Medicare and Medicaid health care services. HealthKeepers, Inc. has served Virginians since 1995. We live and work in your community and understand your unique health care needs. We re ready to put our experience to work for you and help you get the most out of the Commonwealth Coordinated Care program. What are Medicare and Medicaid Medicare Medicare is the federal health insurance program for: people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure). Medicaid Medicaid is a program run by the federal government and the state that helps people with limited incomes and resources pay for long-term services and supports and medical costs. It covers extra services and drugs not covered by Medicare. In Virginia, Medicaid is administered by the Department of Medical Assistance Services (DMAS). Each state decides what counts as income and resources and who qualifies. They also decide what services are covered and the cost for services. States can decide how to run their programs, as long as they follow the federal rules. Medicare and Virginia must approve Anthem HealthKeepers MMP each year. You can get Medicare and Medicaid services through our plan as long as: Y0071_14_19460_T CMS Approved 03/28/2014 4
Chapter 1: Getting started as a member we choose to offer the plan, and Medicare and the State approve the plan. Even if our plan stops operating in the future, your eligibility for Medicare and Medicaid services would not be affected. What are the advantages of this plan You will now get all your covered Medicare and Medicaid services from Anthem HealthKeepers MMP, including prescription drugs. You do not pay extra to join this health plan. Anthem HealthKeepers MMP will help make your Medicare and Medicaid benefits work better together and work better for you. Some of the advantages include: You will have a care team that you helped put together. Your care team may include doctors, nurses, counselors, or other health professionals who are there to help you get the care you need. You will have a care manager. This is a person who works with you, with us, and with your care providers to make sure you get the care you need. You will be able to direct your own care with help from your care team and care manager. The care team and care manager will work with you to come up with a care plan specifically designed to meet your health needs. The care team will be in charge of coordinating the services you need. This means, for example:» Your care team will make sure your doctors know about all medicines you take so they can reduce any side effects.» Your care team will make sure your test results are shared with all your doctors and other providers. What is the Anthem HealthKeepers MMP service area Our service area includes five regions in Virginia and covers the following cities and counties: Central: Amelia, Brunswick, Caroline, Charles City County, Chesterfield, Cumberland, Dinwiddie, Essex, Goochland, Greensville, Hanover, Henrico, King and Queen, King George, King William, Lancaster, Lunenburg, Middlesex, New Kent, Northumberland, Nottoway, Powhatan, Prince George, Richmond County, Southampton, Surry, Sussex, Colonial Heights, City Emporia, City of Franklin, City of Hopewell, City of Petersburg, City of Richmond Y0071_14_19460_T CMS Approved 03/28/2014 5
Chapter 1: Getting started as a member Tidewater: Gloucester, Isle Of Wight, Mathews, Northampton, York, City of Chesapeake, City of Hampton, City of Newport News, City of Norfolk, City of Poquoson, City of Portsmouth, City of Suffolk, City of Virginia Beach, City of Williamsburg Only people who live in our service area can get Anthem HealthKeepers MMP. If you move outside of our service area, you cannot stay in this plan. What makes you eligible to be a plan member You are eligible for our plan as long as: you live in our service area, and you have both Medicare Part A and Medicare Part B, and you are eligible for Medicaid and have no other private or public health coverage (this includes you if you re enrolled in the Elderly or Disabled with Consumer Direction (EDCD) Waiver and/or reside in a nursing facility (NF)); and You are age 21 or over What to expect when you first join a health plan When you first join the plan, you will receive a health risk assessment within the first 30 to 90 days of enrollment, depending upon the kinds of services you need. During the health risk assessment, a nurse or other health care professional will ask you questions about your health and your life. Your answers will help us understand your health care needs better so we can get you the care you need. We might call you and do the assessment over the phone. Or we might set up a time to come to your home and go over the questions with you and your caregiver. If we can t get a hold of you by phone, we will mail you a copy of the questions. You should answer them and send them back to us as soon as you can. Once you re done with the health risk assessment, we will work with you to make a care plan just for you. This plan says what care you need, how often you need it, and who you ll get it from. If Anthem HealthKeepers MMP is new for you, you can keep seeing the doctors you go to now for 180 days after you first enroll. You can also keep getting your prior authorized services for the duration of the prior authorization or for 180 days after you first enroll, whichever is sooner. If you are in a nursing facility at the start of the CCC Program, you may remain in the facility as long as you continue to meet the criteria for nursing facility care, Y0071_14_19460_T CMS Approved 03/28/2014 6
Chapter 1: Getting started as a member unless you or your family prefers to move to a different nursing facility or return to the community. Nursing home criteria are established by the Virginia Department of Medical Assistance Services. After 180 days in our plan, you will need to see doctors and other providers in the Anthem HealthKeepers MMP network. A network provider is a provider who works with the health plan. See Chapter 3 for more information on getting care. What is a care plan A care plan is the plan for what health services you will get and how you will get them. After your health risk assessment, your care team will meet with you to talk about what health services you need and want. Together, you and your care team will make a care plan. Every year, your care team will work with you to update your care plan when the health services you need and want change. Does Anthem HealthKeepers MMP have a monthly plan premium No. About the Member Handbook This Member Handbook is part of our contract with you. This means that we must follow all of the rules in this document. If you think we have done something that goes against these rules, you may be able to appeal, or challenge, our action. For information about how to appeal, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints), or call 1-800-MEDICARE (1-800-633-4227). The contract is in effect for the months you are enrolled in Anthem HealthKeepers MMP between April 1, 2014 and December 31, 2014. What other information will you get from us You should have already gotten an Anthem HealthKeepers MMP member ID card, a Provider and Pharmacy Directory, and a List of Covered Drugs. Y0071_14_19460_T CMS Approved 03/28/2014 7
Chapter 1: Getting started as a member Your Anthem HealthKeepers MMP member ID card Under our plan, you will have one card for your Medicare and Medicaid services, including long-term services and supports and prescriptions. You must show this card when you get any services or prescriptions. Here s a sample card to show you what yours will look like: If your card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. As long as you are a member of our plan, you do not need to use your red, white, and blue Medicare card or your Medicaid card to get services. Keep those cards in a safe place, in case you need them later. Provider and Pharmacy Directory The Provider and Pharmacy Directory lists the providers and pharmacies in the Anthem HealthKeepers MMP network. While you are a member of our plan, you must use network Y0071_14_19460_T CMS Approved 03/28/2014 8
Chapter 1: Getting started as a member providers to get covered services. There are some exceptions when you first join our plan (see page 31). You can request an annual Provider and Pharmacy Directory by calling Member Services at 1-855-817-5787 (TTY/TDD: 1-800-855-2880). You can also download the Provider and Pharmacy Directory at mss.anthem.com/ccc, or you can use our online provider finder. Both Member Services and the website can give you the most up-to-date information about changes in our network providers. What are network providers Network providers are doctors, nurses, and other health care professionals that you can go to as a member of our plan. Network providers also include clinics, hospitals, nursing facilities, and other places that provide health services in our plan. They also include home health agencies, medical equipment suppliers, and others who provide goods and services that you get through Medicare or Medicaid. Network providers have agreed to accept payment from our plan for covered services as payment in full. What are network pharmacies Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptions for our plan members. Use the Provider and Pharmacy Directory to find the network pharmacy you want to use. Except in an emergency, you must fill your prescriptions at one of our network pharmacies if you want our plan to help you pay for them. In emergencies when you may have to use an out-of-network pharmacy, you may need to pay for the prescription and then submit for reimbursement (see Chapter 5, Section A for more information). Call Member Services at 1-855-817-5787 (TTY: 1-800-855-2880) Monday through Friday from 8 a.m. to 8 p.m. local time for more information or to get a copy of the Provider and Pharmacy Directory. You can also see the Provider and Pharmacy Directory at mss.anthem.com/ccc or download it from this website. Both Member Services and the website can give you the most up-to-date information about changes in our network pharmacies and providers. List of Covered Drugs The plan has a List of Covered Drugs. We call it the Drug List for short. It tells which prescription drugs are covered by HealthKeepers, Inc. Y0071_14_19460_T CMS Approved 03/28/2014 9
Chapter 1: Getting started as a member The Drug List also tells you if there are any rules or restrictions on any drugs, such as a limit on the amount you can get. See Chapter 5: Getting your outpatient prescription drugs for more information on these rules and restrictions. Each year, we will send you a copy of the Drug List, but some changes may occur during the year. To get the most up-to-date information about which drugs are covered, visit mss.anthem.com/ccc or call 1-855-817-5787 (TTY: 1-800-855-2880). The Explanation of Benefits When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Explanation of Benefits (or EOB). The Explanation of Benefits tells you the total amount you have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 gives more information about the Explanation of Benefits and how it can help you keep track of your drug coverage. An Explanation of Benefits summary is also available upon request. To get a copy, please contact Member Services. How can you keep your membership record up to date You can keep your membership record up to date by letting us know when your information changes. The Anthem HealthKeepers MMP network providers and pharmacies need to have the right information about you. They use your membership record to know what services and drugs you get and how much it will cost you. Because of this, it is very important that you help us keep your information up-to-date. Let us know the following: If you have any changes to your name, your address, or your phone number If you have any changes in any other health insurance coverage, such as from your employer, your spouse s employer, or workers compensation If you have any liability claims, such as claims from an automobile accident If you are admitted to a nursing facility or hospital If you get care in an out-of-area or out-of-network hospital or emergency room If your caregiver or anyone responsible for you changes If you are part of a clinical research study Y0071_14_19460_T CMS Approved 03/28/2014 10
Chapter 1: Getting started as a member If any information changes, please let us know by calling Member Services at 1-855-817-5787 (TTY/TDD: 1-800-855-2880). Do we keep your personal health information private Yes. Laws require that we keep your medical records and personal health information private. We make sure that your health information is protected. For more information about how we protect your personal health information, see our Notice of Privacy Practices on page 118. Y0071_14_19460_T CMS Approved 03/28/2014 11
Chapter 2: Important phone numbers and resources Chapter 2: Important phone numbers and resources Table of Contents A. How to contact Anthem HealthKeepers MMP Member Services... 14 Contact Member Services about:... 14 Questions about the plan... 14 Questions about claims, billing or member cards... 14 Coverage decisions about your health care... 14 Appeals about your health care... 15 Complaints about your health care... 15 Coverage decisions about your drugs... 15 Appeals about your drugs... 15 Complaints about your drugs... 16 Payment for health care or drugs you already paid for... 16 B. How to contact your Care Manager... 17 Contact your care manager about:... 17 Questions about your health care... 17 Assistance with appointment scheduling... 17 Questions about getting behavioral health services, transportation, and long-term services and supports (LTSS)... 18 C. How to contact the Nurse Advice Call Line... 19 Contact Care On Call about:... 19 Questions about your health care... 19 D. How to contact the Behavioral Health Crisis Line... 19 Y0071_14_19460_T CMS Approved 03/28/2014 12
Chapter 2: Important phone numbers and resources Contact the Behavioral Health Crisis Line about:... 19 Questions about behavioral health services... 19 E. How to contact the State Health Insurance Assistance Program (SHIP)... 20 Contact VICAP about:... 20 Questions about your Medicare health insurance... 20 F. How to contact the Quality Improvement Organization (QIO)... 20 Contact VHQC about:... 21 Questions about your health care... 21 G. How to contact Medicare... 21 H. How to contact Medicaid... 22 I. How to contact the Office of the State Long-Term Care Ombudsman... 23 J. How to contact the Office of the Managed Care Ombudsman... 23 Y0071_14_19460_T CMS Approved 03/28/2014 13
Chapter 2: Important phone numbers and resources How to contact Anthem HealthKeepers MMP Member Services CALL 1-855-817-5787 This call is free. TTY 1-800-855-2880 Call us Monday through Friday from 8 a.m. to 8 p.m. local time. We have free interpreter services for people who do not speak English. This call is free. FAX 1-855-817-5791 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Call us Monday through Friday from 8 a.m. to 8 p.m. local time. WRITE WEBSITE 2015 Staples Mill Rd. Mail Drop VA2002-N500 Richmond, VA 23230 mss.anthem.com/ccc Contact Member Services about: Questions about the plan Questions about claims, billing or member cards Coverage decisions about your health care A coverage decision about your health care is a decision about:» your benefits and covered services, or» the amount we will pay for your health services. Call us if you have questions about a coverage decision about health care. To learn more about coverage decisions, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Y0071_14_19460_T CMS Approved 03/28/2014 14
Chapter 2: Important phone numbers and resources Appeals about your health care An appeal is a formal way of asking us to review a decision we made about your coverage and asking us to change it if you think we made a mistake. To learn more about making an appeal, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Complaints about your health care You can make a complaint about us or any provider (including a non-network or network provider). A network provider is a provider who works with the health plan. You can also make a complaint about the quality of the care you got to us or to the Quality Improvement Organization (see Section F below, How to contact the Quality Improvement Organization). If your complaint is about a coverage decision about your health care, you can make an appeal (see the section above, Appeals about your health care). You can send a complaint about Anthem HealthKeepers MMP right to Medicare. You can use an online form at https://www.medicare.gov/medicarecomplaintform/home.aspx. Or you can call 1-800- MEDICARE (1-800-633-4227) to ask for help. To learn more about making a complaint about your health care, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Coverage decisions about your drugs A coverage decision about your drugs is a decision about:» your benefits and covered drugs, or» the amount we will pay for your drugs. This applies to your Part D drugs, Medicaid prescription drugs, and Medicaid over-the-counter drugs. For more on coverage decisions about your prescription drugs, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Appeals about your drugs An appeal is a way to ask us to change a coverage decision. To appeal a coverage decision about a drug, call Member Services or submit your appeal in writing: Y0071_14_19460_T CMS Approved 03/28/2014 15
Chapter 2: Important phone numbers and resources Mail to: Complaints, Appeals and Grievances HealthKeepers, Inc. P.O. Box 61116 Virginia Beach, VA 23466-1599 Fax to: 1-855-856-1724 If your appeal is about a: Part D drug Non-Part D drug (these have an asterisk next to them in the Drug List) Here s what to do: You must file an appeal within 60 days of the coverage decision. You must file an appeal within 60 days of the coverage decision. You ll receive a decision within: 7 calendar days 30 calendar days (plus 14 day extension) For more on making an appeal about your prescription drugs, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Complaints about your drugs You can make a complaint about us or any pharmacy. This includes a complaint about your prescription drugs. If your complaint is about a coverage decision about your prescription drugs, you can make an appeal. (See the section above, Appeals about your drugs.) You can send a complaint about Anthem HealthKeepers MMP right to Medicare. You can use an online form at https://www.medicare.gov/medicarecomplaintform/home.aspx. Or you can call 1-800-MEDICARE (1-800-633-4227) to ask for help. For more on making a complaint about your prescription drugs, see Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Payment for health care or drugs you already paid for For more on how to ask us to pay you back, or to pay a bill you have gotten, see Chapter 7: Asking us to pay our share of a bill you have gotten for covered services or drugs. Y0071_14_19460_T CMS Approved 03/28/2014 16
Chapter 2: Important phone numbers and resources If you ask us to pay a bill and we deny any part of your request, you can appeal our decision. See Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints), for more on appeals. How to contact your Care Manager With Anthem HealthKeepers MMP, you can get help from a care manager. Your care manager will help you keep track of all your doctors, medicines and services. He or she will keep your providers and caregivers up-to-date on what you need to stay healthy. Your care manager can even help you set up appointments, get rides to the doctor or get help from someone who speaks your language. To get in touch with a care manager: CALL 1-855-817-5787 This call is free. TTY 1-800-855-2880 Available 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English. This call is free. FAX 1-855-817-5791 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Available 24 hours a day, 7 days a week WRITE 2015 Staples Mill Rd. Mail Drop VA2002-N500 Richmond, VA 23230 Contact your care manager about: Questions about your health care Assistance with appointment scheduling Y0071_14_19460_T CMS Approved 03/28/2014 17
Chapter 2: Important phone numbers and resources Questions about getting behavioral health services, transportation, and long-term services and supports (LTSS) Long-term services and supports (LTSS) are a variety of services and supports that help elderly individuals and individuals with disabilities meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over a long period of time, usually in homes and communities, but also in facility-based settings such as nursing facilities. Sometimes you can get help with your daily health care and living needs. You might be able to get these services:» Skilled nursing care» Physical therapy» Occupational therapy» Speech therapy» Medical social services» Home health care» Adult day health care» Assistive technology» Environmental modification» Personal care (agency- and consumer-directed)» Personal emergency response system (PERS) installation and may or may not include monthly monitoring. This is not a stand-alone service and must be authorized in addition to one of the other services available in this waiver.» Medication monitoring (can only be received in conjunction with PERS)» Respite care (agency- and consumer-directed)» Transition coordination» Transitional services Y0071_14_19460_T CMS Approved 03/28/2014 18
Chapter 2: Important phone numbers and resources How to contact the Nurse Advice Call Line CALL TTY 1-866-864-2544 This call is free. Care On Call is available 24 hours a day, 7 days a week, 365 days a year. We have free interpreter services for people who do not speak English. 1-800-855-2880 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Available 24 hours a day, 7 days a week, 365 days a year Contact Care On Call about: Questions about your health care Sometimes you ll have health questions late at night, on the weekends or on holidays. We understand. No matter what day or time it is, you can talk to a registered nurse by calling Care On Call. How to contact the Behavioral Health Crisis Line CALL 1-855-817-5787. This call is free. 24 hours a day, 7 days a week, 365 days a year We have free interpreter services for people who do not speak English. TTY 1-800-855-2880 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. 24 hours a day, 7 days a week, 365 days a year Contact the Behavioral Health Crisis Line about: Questions about behavioral health services Y0071_14_19460_T CMS Approved 03/28/2014 19
Chapter 2: Important phone numbers and resources How to contact the State Health Insurance Assistance Program (SHIP) The State Health Insurance Assistance Program (SHIP) gives free health insurance counseling to people with Medicare. In Virginia, the SHIP is called the Virginia Insurance Counseling and Assistance Program (VICAP). VICAP is not connected with any insurance company or health plan. CALL 1-800-552-3402 TTY TTY users dial 711 WRITE EMAIL WEBSITE Virginia Insurance Counseling and Assistance Program 1610 Forest Avenue, Suite 100 Henrico, Virginia 23229 aging@dars.virginia.gov http://www.vda.virginia.gov/vicap2.asp Contact VICAP about: Questions about your Medicare health insurance VICAP counselors can:» help you understand your rights,» help you understand your plan choices, and» answer your questions about changing to a new plan. How to contact the Quality Improvement Organization (QIO) Our state has an organization called a Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Virginia Health Quality Center (VQHC), Virginia s QIO, is not connected with our plan. CALL 1-800-545-3814 WRITE VHQC 9830 Mayland Drive, Suite J Richmond, VA 23233 Y0071_14_19460_T CMS Approved 03/28/2014 20
Chapter 2: Important phone numbers and resources EMAIL WEBSITE Send an email using the form at www.vhqc.org. www.vhqc.org Contact VHQC about: Questions about your health care You can make a complaint about the care you have received if:» You have a problem with the quality of care,» You think your hospital stay is ending too soon, or» You think your home health care, skilled nursing facility care, or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon. How to contact Medicare Medicare is the federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services, or CMS. CALL 1-800-MEDICARE (1-800-633-4227) Calls to this number are free, 24 hours a day, 7 days a week. TTY 1-877-486-2048 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Y0071_14_19460_T CMS Approved 03/28/2014 21
Chapter 2: Important phone numbers and resources WEBSITE http://www.medicare.gov This is the official website for Medicare. It gives you up-to-date information about Medicare. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print right from your computer. You can also find Medicare contacts in your state by selecting Help & Resources and then clicking on Phone numbers & websites. The Medicare website has the following tool to help you find plans in your area: Medicare Plan Finder: Provides personalized information about Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. Select Find health & drug plans. How to contact Medicaid If you don t have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare at the number above and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you. Medicaid helps with medical and long-term services and supports costs for people with limited incomes and resources. You are enrolled in Medicare and in Medicaid. If you have questions about your Medicaid eligibility, contact the Department of Social Services in the city or county where you live. If you have questions about the services you get under Medicaid, call the Department of Medical Assistance Services (DMAS). Contact information for DMAS is in the table below. CALL 804-786-6145 TTY 1-800-343-0634 WRITE EMAIL Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, Virginia 23219 dmasinfo@dmas.virginia.gov Y0071_14_19460_T CMS Approved 03/28/2014 22
Chapter 2: Important phone numbers and resources WEBSITE http://www.dmas.virginia.gov You can also get information about Medicaid from your local Department of Social Services. To find out how to contact your local agency, visit www.dmas.virginia.gov/localagency. How to contact the Office of the State Long-Term Care Ombudsman The Office of the State Long-Term Care Ombudsman can help you solve problems with the care or services you are receiving. They can help you file a complaint or an appeal with our plan. CALL 1-800-552-3402 TTY 1-800-552-3402 WRITE Office of the State Long-Term Care Ombudsman Virginia Department for Aging and Rehabilitative Services 8004 Franklin Farms Drive Henrico, Virginia 23229 FAX 804-662-9140 WEBSITE http://www.elderrightsva.org How to contact the Office of the Managed Care Ombudsman The Office of the Managed Care Ombudsman helps people whose health insurance is provided by a Managed Care Health Insurance Plan. It helps to protect the interests of consumers by assisting consumers in understanding their rights. CALL 1-877-310-6560, select option 1 TTY 804-371-9206 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. WRITE EMAIL Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, Virginia 23218 ombudsman@scc.virginia.gov Y0071_14_19460_T CMS Approved 03/28/2014 23
Chapter 2: Important phone numbers and resources FAX 804-371-9944 WEBSITE www.scc.virginia.gov/boi/omb Y0071_14_19460_T CMS Approved 03/28/2014 24
Chapter 3: Using the plan s coverage for your health care and other services Chapter 3: Using the plan s coverage for your health care and other covered services Table of Contents A. About services, covered services, providers, and network providers... 27 B. Rules for getting your health care, behavioral health, and long-term services and supports covered by the plan... 27 C. Your care manager... 28 D. Getting care from primary care providers, specialists, other network providers, and out-ofnetwork providers... 29 Getting care from a primary care provider... 29 How to get care from specialists and other network providers... 30 What if a network provider leaves our plan... 31 How to get care from out-of-network providers... 31 E. How to get long-term services and supports (LTSS)... 32 F. How to get self-directed care... 32 G. How to get behavioral health services... 33 H. How to get transportation services... 33 I. How to get covered services when you have a medical emergency or urgent need for care... 33 Getting care when you have a medical emergency... 33 Getting urgently needed care... 35 J. What if you are billed directly for the full cost of services covered by our plan... 35 What should you do if services are not covered by our plan... 35 K. How are your health care services covered when you are in a clinical research study... 36 What is a clinical research study... 36 Y0071_14_19460_T CMS Approved 03/28/2014 25
Chapter 3: Using the plan s coverage for your health care and other services When you are in a clinical research study, who pays for what... 37 Learning more... 37 L. How are your health care services covered when you are in a religious non-medical health care institution... 37 What is a religious non-medical health care institution... 37 What care from a religious non-medical health care institution is covered by our plan... 38 M. Rules for owning durable medical equipment... 38 Will you own your durable medical equipment after making a certain number of payments under our plan... 39 What happens to payments you have made for durable medical equipment if you switch to Medicare... 39 Y0071_14_19460_T CMS Approved 03/28/2014 26
Chapter 3: Using the plan s coverage for your health care and other services About services, covered services, providers, and network providers Services are health care, long-term services and supports, supplies, behavioral health, prescription and over-the-counter drugs, equipment and other services. Covered services are any of these services that our plan pays for. Covered health care and long-term services and supports are listed in the Benefits Chart in Chapter 4: Benefits Chart. Providers are doctors, nurses, and other people who give you services and care. The term providers also includes hospitals, home health agencies, clinics, and other places that give you health care services, medical equipment, and long-term services and supports. Network providers are providers who work with the health plan. These providers have agreed to accept our payment as full payment. Network providers bill us directly for care they give you. When you see a network provider, you usually pay nothing for covered services. Rules for getting your health care, behavioral health, and long-term services and supports covered by the plan Anthem HealthKeepers MMP covers all services covered by Medicare and Medicaid. This includes behavioral health, long-term care and prescription drugs. HealthKeepers, Inc. will generally pay for the health care and services you get if you follow the plan rules. To be covered: The care you get must be a plan benefit. This means that it must be included in the plan s Benefits Chart. (The chart is in Chapter 4: Benefits Chart of this handbook). The care must be medically necessary. Medically necessary means you need services to prevent, diagnose, or treat your medical condition or to maintain your current health status, or an item or service provided for the diagnosis or treatment of your condition consistent with standards of medical practice. This includes care that keeps you from going into a hospital or nursing home. You must have a network primary care provider (PCP) who has ordered the care or has told you to see another doctor. As a plan member, you must choose a network provider to be your PCP.» In most cases, your network PCP must give you approval before you can use other providers in the plan s network. This is called a referral. To learn more about referrals, see page 30. Y0071_14_19460_T CMS Approved 03/28/2014 27
Chapter 3: Using the plan s coverage for your health care and other services» You do not need a referral from your PCP for emergency care or urgently needed care or to see a woman s health provider. You can get other kinds of care without having a referral from your PCP. To learn more about this, see page 30. To learn more about choosing a PCP, see page 29.» Please note: In your first 180 days with our plan, you may continue to see your current providers, at no cost, including providers that are not a part of our network. During the 180 days, our care manager will contact you to help you find providers in our network. After 180 days, we will no longer cover your care if you continue to see out-of-network providers. In addition, we will allow you to maintain your prior authorized services for the duration of the prior authorization or for 180 days after you first enroll, whichever is sooner. If you are in a nursing facility at the start of the CCC Program, you may remain in the facility as long as you continue to meet the criteria for nursing facility care, unless you or your family prefers to move to a different nursing facility or return to the community. Nursing home criteria are established by the Virginia Department of Medical Assistance Services. You must get your care from network providers. Usually, the plan will not cover care from a provider who does not work with the health plan. Here are some cases when this rule does not apply:» The plan covers emergency or urgently needed care from an out-of-network provider. To learn more and to see what emergency or urgently needed care means, see page 33.» If you need care that our plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. The out-of-network provider must request precertification (ask for our permission) before giving you services. In this situation, we will cover the care at no cost to you. To learn about getting approval to see an out-of-network provider, see page 31.» The plan covers kidney dialysis services when you are outside the plan s service area for a short time. You can get these services at a Medicare-certified dialysis facility.» When you first join the plan, you can continue seeing any out-of-network providers you see now for 180 days. Your care manager With Anthem HealthKeepers MMP, you can get help from a care manager. Your care manager will help you keep track of all your doctors, medicines and services. He or she will Y0071_14_19460_T CMS Approved 03/28/2014 28
Chapter 3: Using the plan s coverage for your health care and other services keep your providers and caregivers up-to-date on what you need to stay healthy. Your care manager can even help you set up appointments, get rides to the doctor or get help from someone who speaks your language. He or she will also help you arrange long-term services and supports if you need them. See Chapter 2, Section B, How to contact your Care Manager, to find out how to get in touch with a care manager. To change your care manager, call Member Services. Getting care from primary care providers, specialists, other network providers, and out-of-network providers Getting care from a primary care provider You must choose a primary care provider (PCP) to provide and manage your care. What is a PCP, and what does the PCP do for you Your PCP is your main health care provider. Your PCP will keep your medical records and get to know your health needs over time. You ll see your PCP for your regular checkups and well visits. If you get sick, your PCP will be the first person who gives you care. He or she will prescribe medicines for you, request precertification for services you need, and give you referrals to specialists and other providers if needed. What types of providers may act as a PCP Your PCP could be a family doctor, OB/GYN, nurse practitioner or physician assistant. He or she also could be a specialist who gives primary care. You can also choose a federally qualified health center (FQHC), a rural health clinic or a local health department or similar community clinic to act as your PCP. How do you choose your PCP When you choose a PCP, you should: choose a provider that you use now or choose a provider who has been recommended by someone you trust or choose a provider whose offices are easy for you to get to To see a list of PCPs in our network, look in the Provider and Pharmacy Directory. PCPs are listed by city and county, so you can find one close to where you live and work. The directory also shows you what languages are spoken in the PCP s office. If you need help choosing a PCP, call Member Services. Changing your PCP Y0071_14_19460_T CMS Approved 03/28/2014 29
Chapter 3: Using the plan s coverage for your health care and other services You may change your PCP for any reason, at any time. Also, it s possible that your PCP might leave our plan s network. We can help you find a new PCP. To change your PCP, call Member Services. Choose your PCP from the list in the Anthem HealthKeepers MMP Provider and Pharmacy Directory. A Member Services representative can offer help if you need it. You can start seeing your PCP on the first day of the month following your request. For example, if you ask to change your PCP on September 13th, your PCP change will be effective on October 1st. We ll send you a new Anthem HealthKeepers MMP ID card with your new PCP s name and phone number. Services you can get without first getting approval from your PCP In most cases, you will need approval from your PCP before seeing other providers. This approval is called a referral. You can get services like the ones listed below without first getting approval from your PCP: Emergency services from network providers or out-of-network providers. Urgently needed care from network providers. Urgently needed care from out-of-network providers when you can t get to network providers (for example, when you are outside the plan s service area). Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are outside the plan s service area. (Please call Member Services before you leave the service area. We can help you get dialysis while you are away.) Flu shots, hepatitis B vaccinations, and pneumonia vaccinations as long as you get them from a network provider. Routine women s health care and family planning services. Routine women s health care includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams. You ll still need to get those services from a network provider. You can get family planning services from any provider, in or out of network. Additionally, if you are eligible to receive services from Indian health providers, you may see these providers without a referral. How to get care from specialists and other network providers A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples: Oncologists care for patients with cancer. Cardiologists care for patients with heart problems. Orthopedists care for patients with bone, joint, or muscle problems. Y0071_14_19460_T CMS Approved 03/28/2014 30
Chapter 3: Using the plan s coverage for your health care and other services If you need specialist care, your PCP will give you a referral to the right doctor or other health care provider who can give you the kind of care you need. For some services, you might need prior authorization. Prior authorization means that you need approval from us before getting a specific service or drug. Your doctor or other health care provider will request prior authorization for services they feel you need. To find out which services require prior authorization, see the Benefits Chart in Chapter 4: Benefits Chart. Your PCP may only work with a certain hospital or group of specialists. This is why you have to get a referral from your PCP before you see a specialist. If you have questions about the specialists or hospitals your PCP works with, contact your PCP or Member Services. What if a network provider leaves our plan A network provider you are using might leave the plan. If that happens, we will help make sure you keep getting the care you need. First, we will send you a letter telling you your provider has left the network. If any of your providers leaves the network, someone will reach out to you within 15 days. If your PCP leaves the network, we can help you switch to another PCP. Choose a PCP from the list in our Provider and Pharmacy Directory. If you need help picking the right PCP for you, Member Services can help. If you are in the middle of treatment, we will help you keep getting the care you need. If your specialist leaves the network, call your PCP right away. Your PCP will give you a referral to another specialist who he or she works with. If a long-term services and supports provider leaves the network, call your care manager. He or she can help you find a new provider and will make sure your services don t get interrupted. You can also call Member Services if you have questions about changing providers. How to get care from out-of-network providers Most services will be provided by our network providers. If you need a service that cannot be provided within our network, we will pay for the cost of an out-of-network provider. We ll cover services from an out-of-network provider: For emergency or urgently needed care If you need dialysis In cases of temporary detention/emergency custody orders Y0071_14_19460_T CMS Approved 03/28/2014 31
Chapter 3: Using the plan s coverage for your health care and other services If you need family planning services During an approved continuity of care period, meaning we gave you permission to keep seeing an out-of-network provider and have an agreement with that provider Please note: If you go to an out-of-network provider, the provider must be eligible to participate in Medicare and/or Medicaid. We cannot pay a provider who is not eligible to participate in Medicare and/or Medicaid. If you go to a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get. Providers must tell you if they are not eligible to participate in Medicare. How to get long-term services and supports (LTSS) Long-term services and supports (LTSS) are a variety of services and supports that help elderly individuals and individuals with disabilities meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over a long period of time, usually in homes and communities, but also in facility-based settings such as nursing facilities. Need help getting LTSS Talk to your care manager. Maybe you re doing well and living in your home, but you need a little help. Or maybe you re living in a nursing facility and are ready to go home. Either way, your care manager can help you get the services you need to live where you are comfortable calling home. And as your needs change, your care manager can help you make changes to your services, too. How to get self-directed care Self-directed care, also referred to as self-direction or consumer-direction means you can hire, fire and supervise your own service providers. For this program, you can self-direct your personal care and respite care. During your first health assessment, your care manager and Interdisciplinary Care Team (ICT) will help you decide whether this is the right choice for you. If you choose to self-direct your care, we will help you understand your responsibilities. You have a choice to self-direct your personal care and/or respite care services or get them through an agency at any time. Y0071_14_19460_T CMS Approved 03/28/2014 32